title: Low efficacy of cardioversion of persistent atrial fibrillation with the implantable cardioverter-defibrillator.
abstract: OBJECTIVE
  Atrial fibrillation (AF) and heart failure are conditions that often coexist. Consequently, many patients with an implantable cardioverter-defibrillator (ICD) present with AF. We evaluated the effectiveness of internal cardioversion of AF in patients with an ICD.
  
  
  METHODS
  Retrospectively, we included 27 consecutive ICD patients with persistent AF who underwent internal cardioversion using the ICD. When ICD cardioversion failed, external cardioversion was performed.
  
  
  RESULTS
  Patients were predominantly male (89 %) with a mean (SD) age of 65 ± 9 years and left ventricular ejection fraction of 36 ± 17 %. Only nine (33 %) patients had successful internal cardioversion after one, two or three shocks. The remaining 18 patients underwent external cardioversion after they failed internal cardioversion, which resulted in sinus rhythm in all. A smaller left atrial volume (99 ± 36 ml vs. 146 ± 44 ml; p = 0.019), a longer right atrial cycle length (227 (186-255) vs. 169 (152-183) ms, p = 0.030), a shorter total AF history (2 (0-17) months vs. 40 (5-75) months, p = 0.025) and dual-coil ICD shock (75 % vs. 26 %, p = 0.093) were associated with successful ICD cardioversion.
  
  
  CONCLUSIONS
  Internal cardioversion of AF in ICD patients has a low success rate but may be attempted in those with small atria, a long right atrial fibrillatory cycle length and a short total AF history, especially when a dual-coil ICD is present. Otherwise, it seems reasonable to prefer external over internal cardioversion when it comes to termination of persistent AF.
authors.affiliation: Department of Cardiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, the Netherlands, ione.limantoro@mumc.nl.
authors.forename: I
authors.initials: I
authors.lastname: Limantoro
authors.forename: K
authors.initials: K
authors.lastname: Vernooy
authors.forename: B
authors.initials: B
authors.lastname: Weijs
authors.forename: R
authors.initials: R
authors.lastname: Pisters
authors.forename: L
authors.initials: L
authors.lastname: Debie
authors.forename: H J
authors.initials: HJ
authors.lastname: Crijns
authors.forename: Y
authors.initials: Y
authors.lastname: Blaauw